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Intra-Incisional Antibiotics for Skin Surgery

Infections after dermatologic surgery are infrequent but serious; they cause significant pain, delayed healing, and a far worse appearance of the final scar. This prospective, blinded, randomized, placebo-controlled trial evaluated the effect of intra-incisional antibiotics on the infection rate after surgical repair of 908 surgical wounds, most from Mohs micrographic surgery. The wounds were anesthetized before repair with buffered 1% lidocaine with epinephrine with or without the addition of 0.5 mg/ml of nafcillin. This concentration of nafcillin is 45 times the peak plasma concentration after a 500-mg intravenous dose. Surgical repairs included flaps, grafts, and complex layered closures.

The infection rate was 2.5% in the control group and 0.2% in the nafcillin group, a significant difference. All infections in the control group were caused by Staphylococcus aureus while the single infection in the nafcillin group was caused by Enterobacter aerogenes. The added cost of nafcillin was calculated to be less than one cent per patient.

Comment: For antibiotics to reduce infection rates they must be present in the tissue at the start of surgery. Injecting the antibiotic with the local anesthetic instantly achieves high tissue levels in the area where the antibiotic is needed most. It also reduces potential side effects because the total amount of antibiotic used is less than 0.4% of a systemic dose. However, routine use of prophylactic antibiotics against gram positive organisms may lead to the development of infections with gram negative organisms, which are often harder to treat. Intra-incisional antibiotic injection will be most useful for high-risk anatomic locations, such as the ears, or in immunosuppressed or diabetic patients.

— GJ Hruza

Published in Journal Watch Dermatology August 1, 1998

Citation(s):

Griego RD and Zitelli JA. Intra-incisional prophylactic antibiotics for dermatologic surgery. Arch Dermatol 1998 134 688-692.

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